Towards Informed Use of the Pernkopf Atlas
Leila Lax, B.A., B.Sc.A.A.M., M.Ed., Ph.D
Abstract Knowledge of the dark history and inherent ethical dilemmas of Pernkopf's atlas is essential to individual decisions on use. Seventy-five years after the Holocaust, the legacy of Pernkopf's Atlas of Topographical and Applied Human Anatomy continues to unfold. Informed use of the atlas needs to be integrated in academia and in practice. This paper advocates for the adoption of The Vienna Protocol and improving informed use of the atlas by: (1) updating and inserting an information letter in as many volumes as possible, so that the history can be known before use; (2) conducting and publishing a research study within the medical art community, to examine knowledge of the history of the atlas and elevate awareness; and (3) creating a museum archive and permanent exhibition of the original anatomical illustrations, to document historical facts, disseminate visual evidence, and illuminate embedded controversies. Moving towards informed use, in these ways, provides opportunities for continued ethical discourse, personal reflection and future Holocaust education. Through informed use we memorialize and pay tribute to the Nazi victims portrayed in the atlas.
As a medical art student in the Department of Art as Applied to Medicine, in the Faculty of Medicine, at the University of Toronto from 1980-1983 and as a practicing professional, Pernkopf's Atlas of Topographical and Applied Human Anatomy (1980) and Grant's Atlas of Anatomy (1978) were always on my desk. They were my primary sources of reference.
Grant's Atlas is a regional anatomical atlas that was created at the University of Toronto by anatomist Dr. John C. Boileau Grant and illustrated by Dorothy Foster Chubb and other medical artists, including the first, academic director of the Bachelor of Science program in Art as Applied to Medicine, Prof. Nancy Grahame Joy. Grant's Atlas has been revised, digitized and colorized over the last 30 years by Dr. Anne Agur in collaboration with Dr. Arthur Dalley from Vanderbilt University and teams of medical artists, led by University of Toronto professors, David Mazierski in the 1990's and Nicholas Woolridge in 2016.
The original anatomical illustrations for Grant's Atlas were created in greyscale carbon dust and wash techniques and printed in black and white half-tones (Figure 1). Color overlays were often used - yellow for nerves, red for arteries and blue for veins, to clarify structures for didactic purposes. Key structures were labelled to provide the intended educational focus, along with figure titles that also conveyed view orientation. Grant's Atlas was conceived of as a companion to anatomical dissection for pedagogic purposes, not for surgical reference; it is for this reason that Grant's Atlas and Pernkopf's atlas are distinctly different. Grant's Atlas was and continues to be a primary resource for undergraduate and graduate anatomy, medical, health professional, and allied health education.
Figure 1. Grant's Atlas (1978, fig. 2-28) stomach and the omenta, front view. Permission provided by Wolters Kluwer.
The Pernkopf atlas anatomical illustrations were rendered and labelled in significantly greater detail and painted in full color, in a style that gave the illusion of in-situ visualization. The meticulously dissected anatomical specimens, although preserved and colorless in reality, were painted by the Pernkopf artists in a life-like manner, using vivid tissue color, specular, "wet" highlights and reflections. The extraordinary hyper-realism and extreme detail in the rendering of these anatomical visualizations was matched by highly specific labels and an array of well-organized, fine leaderlines. In fact, after the first printing of the atlas the number of labels were reduced in future publications, and yet still remain the most detailed of any atlas. The Pernkopf atlas was the first anatomical atlas printed in full color. The detailed dissection, painting, labelling and printing techniques enable pin-pointing of anatomical structures for immediate identification and clarification of relationships.
The organization of the pages of the atlas highlight the topographical stratification of the layered anatomical illustrations, that are typically arranged from superficial to deep visualizations. The intended orientation acknowledged by the editor in the Preface of the 1980 edition of the Pernkopf atlas was that it was created "with a view toward the needs of the surgical specialties" (Ferner, in Pernkopf). Hence, as Dr. Susan Mackinnon and colleagues indicate, the Pernkopf atlas can be an important resource in surgery (2021; 2019a; 2019b) and similarly, as Dr. Anne Agur demonstrates (2021), the tracing of structures through stratified visualizations can be useful in clinical diagnosis. The anatomical information encapsulated in these meticulously rendered and labelled visualizations remain unmatched in any other full color or greyscale print or digital atlas.
As a medical art student, I was enthralled by the anatomical details and exceptional watercolor technique used in the Pernkopf illustrations. So much so that I did exercises to master the artists' techniques and use of color. Figure 2 is an example of one such exercise that I did in 1982. It is a compilation of 3 Pernkopf anatomical illustrations from the 1980 publication, volume 2, Figure 237 by Batke dated 1940 and Figures 225 and 261 by Lepier (no date) (Figures 2.a., 2.b., 2.c.). The Pernkopf artists employed the classic style of Renaissance painters, using cool blues, greens and purples in the shadows (never any grey to shade or create form), warm yellows and whites in the contrasting highlights and reflected color in adjacent structures, to achieve a high level of realism and aesthetic balance.
Figure 2. Student exercise after Batke & Lepier by L. Lax (1982),
based on figures 237, 261 and 225, from Pernkopf's atlas, volume 2, 1980.
Figures 2.a., 2.b. & 2.c. From Pernkopf's atlas, volume 2, 1980, permission provided by the Josephinum – Ethics, Collections and History of Medicine, MedUni Vienna. Image credit: 2.a. by Batke (1940; fig. 237) MUW-AD-003250-5-ABB-223; 2.b. by Lepier (no date; fig. 261) MUW-AD-003250-5-ABB-226; 2.c. by Lepier (no date; fig. 225), MUW-ZE-003250-0005-0156r.
Ethical issues around the creation of the Pernkopf atlas remained dormant for forty years after the Holocaust, until Dr. Gerald Weissman published his paper in 1985 on Pernkopf's Nazi affiliation and Prof. David Williams published his seminal paper in 1988 on Pernkopf and his artists in the Journal of Biocommunication (reprinted in this issue). The depth of this Nazi legacy was addressed by Dr. William Seidelman and Dr. Howard Israel (Appendix 1: Dr. Seidelman, personal letter to Dr. Israel 1995; Israel & Seidelman 1996), who brought further attention to this issue by initiating a historic meeting with Yad Vashem officials and representatives from the University of Vienna. The University of Vienna agreed to conduct a detailed investigation on the creation of atlas, the results of which were made public in their 1998 Senatorial Project report (Angetter 2000).
I first became aware of the history of the Pernkopf atlas in 2005, when my University of Toronto colleague and former surgical illustration professor, Margot Mackay gave me a copy of the 1988 Spring volume of the Journal of Biocommunication with David Williams' well-researched paper on Pernkopf and his artists. I am the daughter of Holocaust Survivors. I never dreamt that my personal and professional lives would become intertwined in this way. Over the years I have felt responsible for contributing to the scholarship and preservation of knowledge and artifacts of historical record in this regard.
From the medical art perspective, my focus is on scholarly dissemination to improve informed use of the Pernkopf atlas by:
1. advocating for the creation of an updated information letter to be inserted in as many volumes as possible so that the controversial history of the atlas can be known before use;
2. conducting a research study within the medical art community, to examine knowledge and ethical perceptions on current use in academia and practice; and
3. supporting the creation of a museum archive and permanent exhibition of the original anatomical illustrations to explicate the historical legacy.
In these three ways, opportunities for continued ethical discourse, personal reflection and Holocaust education can be ensured, and can provide necessary acknowledgment to memorialize and honor the nameless victims of the portrayed in this atlas.
Information Letter and Communication
The Vienna Protocol provides us with reasoning and guidance for use of the Pernkopf atlas (Polak, 2021; 2017). The Untermann Protocol within The Vienna Protocol requires that the history be made known before use and "in this way" it says, "the dead are accorded at least some of the dignity to which they are entitled" (Polak, 2021; 2017). One important way that this can be accomplished is with an information letter inserted inside the front cover of each volume of the atlas, to provide potential users with knowledge of the historical facts and ethical issues involved in the creation of the atlas, and then with this information, enable individuals to personally decide on whether to use the atlas or not. This is not a new idea (Appendix 1: Dr. Seidelman, personal letter to Dr. Israel 1995; Seidelman 2017).
In fact, an information letter was created by the University of Vienna, in 1997, signed by Bernd Matouschek, liaison officer, "written on behalf of the Rector of the University of Vienna in the name of Prof. Dr. Alfred Ebenhauer" (Appendix 2). The cover letter states, "I may ask you kindly to add, if possible, the enclosed note of information to your copies of the "Pernkopf-atlases"… all volumes and all editions…" (1997).
The accompanying letter of "Information for the Users of the Pernkopf-atlas" was provided in English and German and indicates:
At present, the possibility cannot be excluded that individual preparations, which were used for drawings… originate from (political) victims of the National Socialist regime. These were delivered by the Wiener Landesgericht (District Court of Vienna). There is also a slight possibility that corpses were delivered from concentrations camps to the Anatomical Institute of the University of Vienna.
It is therefore the ethical responsibility of the individual user to decide whether and in what way he uses this work until the investigation results are published (1997).
The Senatorial investigation report on the University of Vienna Anatomical Institute, published in 1998, concluded that the cadaver register book was missing and was probably destroyed in the air raid of Feb. 7, 1945. They indicate that this was the most important resource where each body assigned to the department of anatomy would have been recorded. Despite the lost document, the Senatorial investigation was able to confirm that:
1377 bodies of executed citizens, including eight of Jewish origin, were assigned to the anatomy department. …Of the eight victims of Jewish origin, identified as such on the basis of the prison chaplain's report, seven bodies were delivered to the department of anatomy.…
With respect to the signatures… it is undisputed that Lepier repeatedly included a swastika in his signature.…
The accusation that some of the illustrations in the anatomical atlas might have been based on executed persons, in particular those of Jewish origin, can neither be confirmed nor negated. Of all the 791 illustrations in Pernkopf's anatomical atlas… roughly half…predate 1937. However, 41 paintings were in fact signed with dates referring to the National Socialist period between 1938 and 1945 and it must be assumed that the models probably came from the group of 1377 executed victims. The remaining 350 illustrations could not be dated and it is possible that some of them were likewise reproduced from Nazi victims (Angetter 2000).
Although the Senatorial Report on the University of Vienna, Anatomical Institute, confirmed the procurement of bodies through the execution of Nazi victims at the District Court, what was forgotten was the necessary update and distribution of the 1997 letter of "Information for the Users of the Pernkopf-atlas." This must not remain undone.
2021 Update: Twenty-four years later, dated July 1, 2021, a new "Note to the Users of Pernkopf's Atlas of Topographical and Applied Human Anatomy" has been created by the Rector, Marcus Müller and the Director of the Josephinum, Prof. Christiane Druml, on behalf of the Medical University of Vienna. We are honoured to publish this important document for this first time in this JBC Special Issue for dissemination, printing and insertion in the atlas.
In addition, the 2021 "Note to the Users" of the atlas could be disseminated worldwide by targeted emails and made accessible as a downloadable PDF on the Josephinum's and the Medical University of Vienna's Websites, with a request for insertion in all volumes of the atlas. It is essential that this updated information "Note to the Users" be disseminated internationally to institutions (e.g., medical and health professional schools, libraries, hospitals and medical art programs) and to individuals who own personal copies, through professional associations, scholarly presentations and publications.
It is also necessary that appropriate protocols be adopted, i.e., the Untermann Protocol and the Vienna Protocol (Polak 2017) when the atlas is being considered for use in academia, whether in the context of an ethics discussion, Holocaust education or a history of medical art class, etc. The history of the atlas should be communicated to students before recommending use, and if available, students should receive a copy of the information "Note." Students should be provided with the opportunity to review the history, personally decide and consent to use, or choose a recommended option or alternative to use of the atlas.
The second important aspect that requires illumination within the medical art community necessitates an examination of students', faculties' and practitioners' use of the Pernkopf atlas, whether or not individuals know of the atlas' tainted history, and what their beliefs are around the ethical issues. Recent survey research has been conducted on nerve surgeons by Yee and colleagues, emanating from Dr. Susan Mackinnon's use of the atlas as a surgical resource (2019a, 2019b), followed by another study by Yee and colleagues on maxillofacial surgeons, initiated by Dr. Howard Israel (2020). A similar study needs to be conducted within the medical art community to examine the ethical dilemmas of use and confront the history of the Pernkopf atlas' Nazi legacy, openly and transparently. It is essential that the study results be disseminated throughout the medical art community to promote awareness, discourse and ethical guidelines for future informed use of the Pernkopf atlas in academia and in practice.
Archive and Permanent Exhibition
The third aspect that I strongly advocate, is for the creation of a museum archive and permanent exhibition of the original Pernkopf anatomical illustrations. Some of the original 791 watercolors are still in existence and until very recently were held by the publishing company, Elsevier, in Munich, Germany (Czech et al. 2021). (Elsevier inherited them in 2003, through a series of corporate mergers and acquisitions, emanating from the 1998 sale of Urban and Schwarzenberg Inc., the original publishers of the Pernkopf atlas.)
The Pernkopf anatomical illustrations are historical artifacts and therefore should move from private ownership into the public domain. Donation and repatriation of the Pernkopf illustrations, from Elsevier to the Medical University of Vienna was initially proposed by Dr. William Seidelman in 1995 at the meeting at Yad Vashem (Appendix 1: Letter from Dr. Seidelman to Dr. Israel 1995).
2021 Update: In Dec. 2019, Elsevier signed an historic agreement, to donate the Pernkopf atlas original anatomical illustrations to the Josephinum. In the summer of 2020, 417 of the original 925 illustrations, from Elsevier's archives (along with 388 printing proofs of the lost originals) were repatriated to the Medical University of Vienna and in January 2021 an announcement was published with details about the donation (Czech et al. 2021).
The Josephinum is the Medical History Museum at the Medical University of Vienna. It holds a rare collection of Italian wax anatomical models, antique medical objects, surgical tools and books. It would be a fitting place to archive and exhibit the original Pernkopf anatomical illustrations, to document and disseminate their history, to educate current and future generations and to memorialize the unknown victims. Furthermore, the Pernkopf legacy and a few of the original watercolors could be shared with Holocaust museums internationally, especially Yad Vashem in Jerusalem, Israel, the Holocaust Museum in Washington, D.C. and the Neuberger Holocaust Education Centre, in Toronto, Canada, as well as on the Internet, for dissemination worldwide.
Recently, the Medical University of Vienna made a commitment to transparency and truthful examination of what occurred there during the Holocaust. An informative exhibition, under the direction of Professor Christiane Druml, curated by Professor Herwig Czech and Dr. Niko Wahl, called "The Vienna Faculty of Medicine 1938 to 1945" was on display at the Josephinum from March 13 to October 6, 2018 (Figure 3). (I went to Vienna to view this exhibit.)
Figure 3. The exhibition took place at the Josephinum, Medical University of Vienna, from March 13 - October 6, 2018. This photo has been licensed and is used with permission of the Österreichische Nationalbibliothek (Austrian National Library, Vienna, Austria), and the Josephinum.
Eighty years after the March 1938 expulsion of all Jewish faculty and students from the Vienna Faculty of Medicine, the university opened its doors to reveal its history and to display numerous remaining artifacts from this dark time. Original documents from medical experiments, like the Dachau salt-water experiments, were on display, as well as a complete set of the first publication of all four German volumes of the Pernkopf atlas, under a glass box.
The catalogue prologue, written by Prof. Dr. Markus Muller, current Rector of the Medical University of Vienna and Professor Christiane Druml, highlights the significance of this endeavor and reads:
We are shaped by our history; yet to the same extent we shape our history through the ways in which we deal with it, through how we speak about the past, which events we remember in what way, and which we do not; how our collective memory shapes what the individual remembers (Müller & Druml in Czech et. al, 2018).
It is anticipated that a permanent exhibition will be installed at the Josephinum after completion of the current building renovations. However, any permanent exhibition that includes the volumes of the Pernkopf atlas would be incomplete without the original watercolors. These artifacts provide visual evidence and testimony; they carry the historical narrative of the facts(Figure 4). And there are important narratives within the larger narrative that can be easily missed, because facts have been changed, like the removal of the swastikas from most of Lepier's signatures after publication of the first edition of the atlas.
Figure 4. Lepier's signature with swastika Wien (Austria) from Pernkopf's atlas (1963). Permission provided by the Josephinum – Ethics, Collections and History of Medicine, MedUni Vienna. Image credit: MUW-AD-003250-5-ABB-183.
As demonstrated in Dr. Hildebrandt's photo, taken on her visit to Elsevier in Munich, in March 2019 and published herein (Hildebrandt, 2021), the lines of the swastikas in Lepier's signature on some of the anatomical illustrations were removed with sharp object (like an Exacto knife) by picking portions of the vertical swastika line out the surface of the watercolor paper; this left a series of small dots, not visible on reprinting. On other illustrations, as David Williams (2004, 1988) indicated, the swastika was removed in Lepier's signature by painting it out.
Figure 5. Lepier's signature with publisher's marks for removal of the swastika. Permission provided by the Josephinum – Ethics, Collections and History of Medicine, MedUni Vienna. Image credit: MUW-ILL06-179ll-GESAMTBILD.
To me, the removal of the swastikas from the original watercolors is analogous to changing historical facts - deleting details is like erasing evidence (Figure 5). A permanent exhibition with explanations of the historical narratives embedded within the Pernkopf artifacts would document the visual evidence and provide testimony for continued ethical discourse, Holocaust education and informed use of the atlas.
Donation of the Pernkopf anatomical illustrations and creation of a permanent exhibition at the Josephinum also is a way for Elsevier (on behalf of the original publisher Urban & Schwarzenberg Inc.) to honor and memorialize the unknown identities of the victims portrayed in the atlas. It provides an opportunity to publicly acknowledge and responsibly share these historical artifacts with the world.
Informed use of the Pernkopf atlas is an imperative. As an ethical standard, ascertained by The Vienna Protocol (Polak 2017), it demands to currently be addressed (Hildebrandt et al. 2021). Moving towards informed use through the dissemination and communication of updated historical information to users of the atlas, a research study on knowledge and ethical use within the medical art community, and the installation of a permanent exhibition of the original anatomical illustrations, are important next steps. The Nazi legacy of the Pernkopf atlas continues to unfold and remains relevant. Repatriation of the anatomical illustrations to the Josephinum at the Medical University of Vienna – to be shared, physically and virtually - with Holocaust museums internationally and on the Internet with individuals and institutions worldwide, will ensure preservation of visual testimony, documentation of historical facts, and illuminate ethical concerns. Informed use is essential to future Holocaust educational initiatives (Roelcke et al. 2021; Hildebrandt 2020; Lax 2020; Seidelman et al. 2019; Horton 2019) and gives us pause, to remember and pay tribute to the unknown victims portrayed in the atlas.
Addendum: I am delighted to report that since the Toronto Symposium, in November 2019, that 2 of the 3 items advocated for in this presentation/paper have been realized through the advocacy of the Medical University of Vienna, and are noted in "2021 Updates" within this paper. I am grateful to Professors Herwig Czech, Christiane Druml, Wolfgang Weninger and Rector Markus Müller of the Medical University of Vienna, for their advocacy and contributions to this 2021 JBC Special Issue, and for elucidating the Medical University of Vienna perspective, and creating the important 2021 "Note" to inform future users about the history of the atlas.
Acknowledgements: Special thanks to Dr. Sabine Hildebrandt for sharing with me the 1997 cover letter and letter of "Information for the Users of the Pernkopf-atlas." Thank you to the Neuberger Holocaust Education Centre for their gracious support and inclusion of our Symposium in Holocaust Education Week 2019 and to Biomedical Communications at the University of Toronto for their generous sponsorship of the Symposium.
Dedication:The Toronto Symposium and this Journal of Biocommunication Special Issue are dedicated to the memory of all Nazi victims and in honor of the Survivors and their families.
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About the Author
Leila Lax, an assistant professor in the Master of Science program in Biomedical Communications, Institute of Medical Science, Faculty of Medicine, University of Toronto, recently retired from teaching after 37 years. Leila taught courses in medical legal visualization and conducted large-scale, curricular design research in medical, interprofessional and health sciences education. She held the 2-time distinction of AMI Commissioner on the Accreditation Review Committee for the Medical Illustrator. Leila's masters and doctoral degrees are in Higher Education with specializations in health professions education and collaborative knowledge building. As a Senior Research Scientist, Institute for Knowledge Innovation and Technology, she continues to coordinate the Palliative Care eLearning Program. Leila's work has been recognized by numerous awards, since her early days as a medical illustrator, for her teaching, research publications, and co-design curricular initiatives. In 2021, Leila was honored with an Ontario Government Volunteer Recognition Award.
Leila Lax, B.A., B.Sc.A.A.M., M.Ed., Ph.D.
Assistant Professor (retired),
Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto
The author has chosen to license this content under a Creative Commons Attribution, NonCommercial, NoDerivatives 4.0 International License.
Authorization for publication of images from Pernkopf's atlas has been granted for use in this article only. The atlas images must remain within the context of this article for open-access, scholarship and educational use. The atlas images in this article may not be removed from this article, nor reproduced, nor distributed, outside of the context of this article, for scholarly, education or commercial purposes, without the expressed permission of the Josephinum.
The Journal of Biocommunication wishes to thank the Josephinum and the Medical University of Vienna for approving the publication of Pernkopf atlas images that used within this Special Issue. These images may appear on the cover, in the Table of Contents and as figures within articles, and are acknowledged with the following image credit:
Josephinum – Ethik, Sammlungen und Geschichte der Medizin, MedUni Wien
Josephinum – Ethics, Collections and History of Medicine, MedUni Vienna
Conflict of Interest Statement
The Journal of Biocommunication Management Board and Editors believe that transparency in academic research is essential. Our JBC authors are now required to disclose any possible conflict of interest when submitting a manuscript. In accordance with the Journal of Biocommunication's editorial policy, no potential conflict of interest has been reported or declared by this author.
Appendix 1: Dr. William Seidelman, personal letter to Dr. Howard Israel, 1995.
Appendix 2: Cover letter and letter of "Information for the Users of the Pernkopf-atlas."